Patient safety guidelines fall short of telling doctors when to say 'sorry'


The first national guidelines telling doctors, nurses and others how to inform patients they have suffered harm while receiving medical treatment are to be released Tuesday, though there is a sticking point over how – or even whether – to use the word “sorry.�

The Canadian Patient Safety Institute guidelines, to be released Tuesday at a news conference, encourage health-care workers to break the news to patients within a day or two of discovering the adverse event, such as a wrong medication dose, hospital-acquired infection or obstetrical trauma during childbirth.

“The patient has a right to know, they’re entitled to know, it’s the right thing to do,â€? said Phil Hassen, chief executive officer of the Canadian Patient Safety Institute. “I think that’s the bottom line.â€?

Disclosing harm is not common practice in most hospitals, even though between 9,250 and 23,750 hospital patients died avoidable deaths in 2000. That same study, published in the Canadian Medical Association Journal in 2004, found that one in 13 adult medical and surgical patients admitted to acute-care hospitals suffered at least one adverse event.

“It has not been the standard to always disclose,â€? Mr. Hassen said in a telephone interview from Edmonton. “There’s a great fear about that, and what we’re saying is that fear is unwarranted.â€?

Under the guidelines, disclosure should include the facts of the harm, an expression of sympathy or regret, a brief review of the investigative process that will follow, an offer of future meetings and a time for questions and answers.

“When harm has occurred, the immediate and ongoing welfare of the patient is of the highest priority,� according to a draft copy of the guidelines, endorsed by 15 national and provincial health organizations. “However, a delay in communication may precipitate anxiety and feelings of abandonment in patients who suspect an adverse event has occurred.�

Patient safety is a hot-button issue in health care, as revelations of improperly sterilized instruments, medication errors and incorrect cancer test results have made news across the country.

Last month, a Quebec neurosurgeon was fined $750 and had his medical licence suspended for 21/2 months after failing to disclose that a broken blade was left in a patient during an operation. The Collège des médecins du Québec said the patient should have immediately been told that he had a foreign metal object lodged in his body that could cause serious health problems.

In a telephone interview from Vancouver, Canadian Medical Association president Brian Day said he is very pleased with the patient-centred approach of the guidelines, saying they will go to his board for approval, probably in May.

“It’s important to be honest with patients,â€? Dr. Day said. “… And so we believe this document will be a good template and a good guide to physicians in Canada.â€?

The Canadian Medical Protective Association, the doctor’s defence body, was on the working group for the guidelines. But it stopped short of endorsing them – it does not endorse any guidelines, largely because they could be used as a standard in court, said its chief executive officer John Gray.

Consequently, the doctors’ defence body is working on its own disclosure tool kit for physicians, which is expected to come out as early as the end of March.

“We don’t think it’s appropriate for physicians – until they are in possession of all of the facts – to necessarily accept blame or say that ‘I’ve been negligent,’ which is a legal term,â€? Dr. Gray said in a telephone interview from Ottawa. “One can acknowledge that harm has occurred, that it was unexpected, certainly unintended and, if the facts are known that can lead one to a conclusion, certainly one can express regret and even in some cases express an apology.â€?

Indeed, the only controversial part of the document has been over the use of the word ‘sorry.’

Some are concerned it can be interpreted as an admission of liability. Consequently, the guidelines focus largely on expressing regret, sympathy and sometimes using the word sorry, so long as it is used in the right context. Words such as “negligence� and “fault� and “failing to meet the standard of care� should be avoided, the draft guidelines say.

Mike Boyce, vice-president of claims for Healthcare Insurance Reciprocal of Canada, a major provider of health-care liability insurance, said it’s important to be thoughtful during disclosure and to avoid the use of “weasel words.â€?

“If an apology is not sincere, an expression of regret is not sincere, it really becomes self-evident,� said Mr. Boyce, whose group has endorsed the guidelines. “And it actually is offensive to an awful lot of people.�

Indeed, Ryan Sidorchuk, patient safety champion of the World Health Organization, described the guidelines as a good start, but said he would like to see the word ‘sorry’ used more liberally.

“The idea is still out there that saying sorry is somehow an admission of liability,â€? Mr. Sidorchuk said in a telephone interview from Winnipeg. “Where we need to get health care to is the idea that ‘I’m sorry’ is really a human response, it’s not saying. ‘I’m sorry, I’ve done something terrible.’â€?

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